Thursday, January 31, 2013

New in the Literature: Treatment for ACL Tear (BMJ. 2013;346:f232)

In a follow-up of a randomized
controlled trial, a strategy of rehabilitation plus early acute anterior
cruciate ligament (ACL) reconstruction did not provide
better results at 5 years than a strategy of initial rehabilitation with the
option of having a later ACL reconstruction. Results did not differ between
knees surgically reconstructed early or late and those treated with rehabilitation
alone. These results should encourage clinicians and young active adult
patients to consider rehabilitation as a primary treatment option after an
acute ACL tear, say the authors in their article published this month in BMJ.

This study included 121 young,
active adults (mean age 26 years) with acute ACL injury to a previously
uninjured knee. All patients received similar structured rehabilitation. In
addition to rehabilitation, 62 patients were assigned to early ACL
reconstruction and 59 were assigned to the option of having a delayed ACL
reconstruction if needed. One patient was lost to 5-year follow-up.

The main outcome was the change from
baseline to 5 years in the mean value of 4 of the 5 subscales of the knee
injury and osteoarthritis outcome score (KOOS4). Other outcomes included the
absolute KOOS(4) score, all 5 KOOS subscale scores, SF-36, Tegner activity
scale, meniscal surgery, and radiographic osteoarthritis at 5 years.

Thirty (51%) patients assigned to
optional delayed ACL reconstruction had delayed ACL reconstruction (7 between 2
and 5 years). The mean change in KOOS4 score from baseline to 5 years was
42.9 points for those assigned to rehabilitation plus early ACL reconstruction
and 44.9 for those assigned to rehabilitation plus optional delayed
reconstruction (between group difference 2.0 points after adjustment for
baseline score). At 5 years, no significant between-group differences were seen
in KOOS4, any of the KOOS subscales, SF-36, Tegner activity scale, or
incident radiographic osteoarthritis of the index knee. No between-group
differences were seen in the number of knees having meniscus surgery or in a
time-to-event analysis of the proportion of meniscuses operated on. The results
were similar when analyzed by treatment actually received.